Vision Quest

Mary Ellen Egan
Forbes Magazine
09.15.03

Laser eye surgery has worked for millions--but goes awry in 18,000 patients a year. A new approach aims to fix that.

Last year Edmond Heinbockel, a 45-year-old software executive in San Luis Obispo, Calif., screwed up the courage to get lasik, the laser eye surgery performed on 600,000 people each year. But during the simple procedure something went wrong. The ophthalmologist made too short a cut in the corneal flap of Heinbockel's right eye and had to abort the operation. The patient had to wait six months for the cornea to heal before he could try the surgery again--a blessing in disguise.

Two months ago Heinbockel had a new kind of eye surgery called wavefront, approved by the Food & Drug Administration in October 2002. Now he has "super vision," better than 20/20. "I'm seeing better than I've seen in my entire life," he says.

Though some 3.7million Americans have had successful lasik surgery since 1995, problems such as bad night vision, cloudiness, glare and halos occur in about 3% of patients--upwards of 18,000 people a year. The new wavefront approach reduces flaws to just 1% of cases and fixes vision problems lasik cannot. Using wavefront, doctors create richly detailed maps of the cornea, using a focusing trick developed for high-powered telescopes. The maps are used to guide a correcting laser knife so precisely that lasik's problems are avoided while acuity--the amount of detail the eye can perceive--improves markedly. Results are often better than 20/20.

Switzerland-based Alcon, the world's biggest ophthalmic device firm, first tested wavefront on 200 patients in 2001. Nine out of ten had their vision improved to at least 20/20, with 136 seeing 20/15 (meaning they could see, at 20 feet, images that should have been visible only at 15 feet). Since then 20,000 procedures have been done. It's hard to find an eye doctor who isn't thrilled with wavefront. It is the first major development in laser eye surgery in more than ten years. "Now we can deal with the intricacies that make up vision," says Stephen Lane, president of the American Society of Cataract & Refractive Surgery.

Alcon's chief rival, Visx of Santa Clara, Calif., introduced a wavefront machine in May using a slightly different technique. The procedure costs about $2,500 per eye, or 20% more than lasik. It isn't covered by insurance (nor is lasik),and it is only approved to treat nearsightedness, meaning an inability to see well at far distances. Alcon has trials under way for farsightedness and the correction of lasik errors, uses not currently approved by the FDA.

Stephen Brint, an ophthalmology professor at Tulane University School of Medicine in New Orleans and a paid adviser to Alcon, says complications from wavefront, while fewer, are typically of the same kind as lasik's.

The procedure takes about 15 minutes. As with lasik, a surgeon cuts a flap in the cornea and peels it back to expose the middle part of the cornea, the stroma. The doctor reshapes the stroma by applying tiny pulses from a computer-controlled laser. The goal in both procedures is to flatten a too-steep cornea in nearsighted people, steepen a flat one for the farsighted and smooth a bumpy cornea for the astigmatic.

But lasik and wavefront are as different as ordering a suit off the rack and being fitted for a custom-tailored one. With lasik, your eyes are tested in the same way as when you buy glasses or contacts; the doctor flips a set of lenses in front of each eye until finding one that makes you see better. Show up with 20/60 vision and you get the same job as everyone else with 20/60, even though people with the same vision can have different patterns of subtle bumps on the cornea.

Wavefront uses 200 tiny lenses to map the cornea, taking a far more accurate reading of surface irregularities. Alcon's LadarWave shines an infrared laser through the cornea. It reflects back from the retina in the rear of the eye and passes through the lenses. Distortions in the returning light waves signal corneal bumps and dips, and a digital camera records the scene. Then software, originally designed to help astronomers see stars through the distortion of the Earth's atmosphere, creates a 3-D map to control the surgeon's laser.

Thomas Wilson, 57, had two lasik surgeries that left him with halos and night vision problems. Even more galling, he still had to wear glasses. Wavefront improved his left eye to 20/15; in a year he hopes to fix the farsightedness in his right one. His original lasik doctors "thought I should be satisfied with my results," he fumes.